Certificate Requests

Please complete the form below. All fields with asterisks are required. Note that no changes will take effect until you receive a confirmation from us.


I. Please identify yourself
	Your name

	Insured

	Insured shown on certificate

	Phone*

	Fax

	Email*




II. Additional interest / Certificate holder
	Company Name*

	Address*

	City*

	State*	Zip Code -

	Phone

	Fax

	Email




III. Additional interest nature (skip if certificate is for evidence of insurance only)
	Additional Interest Nature	Addt'l Insured
		Addt'l Insured Lessor & Loss Payee(Leased Equipment) Addt'l Insured & Loss Payee for Auto Policy Addt'l Insured and Mortgagee Addt'l Insured Manager/Lessor (CG 20 24) - Landlord Owner, Lessee, Contractor (Form B, CG 20 10) Work Performed Additional Insured Vendor Loss Payee




IV. Interest in relation to
	Vehicle

	Equipment

	Location

	Job

	Other




V. Policies to be shown
	Policies to be shown	General Liability Automobile Umbrella
		Workers Compensation Property




VI. Description to read





VII. Deliver certificate by
	Mail

	Fax

	Email




VIII. Special Instructions



Please note that no changes will take effect until we review your request and you receive a confirmation from us. This will usually occur during normal business hours.

Plainview • New York City • Westhampton • Saratoga

Tel: (516) 938-9000 • Email: cbs@cbsinsurance.com